Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Forrest Oakes Healthcare during CMS and state inspections, most recent first.
A resident with cerebral infarction and cognitive communication deficit gave $280 to the Medical Records Manager after staff were asked to clean his apartment before discharge. Although the Administrator said the facility would pay staff and the resident would have no out-of-pocket expense, the Medical Records Manager accepted the money, placed it in her work bag, and did not refuse it at the time. Transportation staff reported seeing the exchange, and the DON later confirmed the funds had been returned to the resident.
Failure to complete PASRR screening before admission for a resident with PTSD. The record showed the resident had a prior Level I PASRR letter stating no further screening was needed unless there was a significant change in condition, but the facility admitted the resident without obtaining a new PASRR evaluation. The SS Director said she did not realize a new PASRR was needed, and the Administrator said he was unaware a new evaluation was required and that the SS Director handled PASRR requests.
Incorrect transcription of protective skin care orders: A resident with severe cognitive impairment, limited LE ROM, malnutrition, and pressure-related skin issues had physician orders for Skin Prep to the left great toe and right lateral foot twice daily. The Wound Nurse transcribed both orders to the TAR as daily, and the treatments were documented as completed once daily instead of twice daily. The Wound Nurse confirmed the transcription error, while the NP and DON stated the orders should have been transcribed and carried out correctly.
A resident with chronic respiratory conditions had an order for continuous oxygen at 3 LPM via NC, but survey observations found the concentrator set at 2.5 LPM on multiple occasions. An RN verified the lower setting and stated it should have been 3 LPM, while the MAR showed oxygen checks were initialed on all shifts. The NP, DON, and Administrator all stated staff should verify the concentrator setting matched the ordered flow rate.
Medication storage and dating practices were not followed on the D Hall med cart. Surveyors found an unopened bottle of Rhopressa eye drops that was not refrigerated per the manufacturer label, along with opened, undated Brimonidine Tartrate eye drops, Erythromycin ophthalmic ointment, and Latanoprost eye drops. The MA said she was unaware the eye drops were not dated when opened and confirmed the unopened Rhopressa should have been refrigerated until opened; the DON stated staff were expected to follow manufacturer directions for storage and expiration dating.
A resident with an indwelling urinary catheter was found with the catheter drainage bag lying on the floor, increasing the risk of infection. The bag lacked a hook to secure it to the bed frame, and staff failed to ensure it was properly attached after a recent change. The Unit Manager, Nurse Practitioner, Director of Nursing, and Administrator all acknowledged that the bag should not have been on the floor.
The facility failed to maintain a safe and clean environment, with exposed wires on a bed control cord, dirty PTAC vents, and poorly maintained resident rooms. The Maintenance Director acknowledged the issues but was unable to confirm repair schedules. Housekeeping practices were inadequate, with trash and debris found under a resident's bed. The Administrator emphasized the importance of a well-kept environment, but a lack of coordination between housekeeping and maintenance contributed to the deficiencies.
A facility failed to provide adequate nail and incontinence care for several residents dependent on staff for ADLs. Observations revealed long, jagged, and dirty fingernails, and residents reported wearing wet briefs for extended periods. Interviews indicated staffing shortages and communication issues contributed to these deficiencies, with the DON and IC nurse acknowledging the lack of care.
The facility failed to provide adequate nursing staff, affecting the care of residents needing incontinence and ADL assistance. Interviews revealed that staff were overwhelmed, with only one NA available for over fifty residents at times. The DON acknowledged the staffing issues but faced challenges in implementing solutions.
The facility failed to update care plans for several residents following MDS assessments. A resident's care plan was not revised to remove a fall mat intervention, while another's still included discontinued side rails. Two residents lacked focus areas for ADL care despite needing assistance. Observations and staff interviews confirmed these oversights, highlighting the need for accurate care plan updates.
The facility experienced delays in meal service due to staffing shortages and food temperature issues. On two occasions, meals were served late, affecting residents' meal times. A resident's family expressed difficulty in encouraging the resident to eat due to unpredictable meal delivery. The delays were attributed to staff call-outs, a dropped meal, and the need to reheat food items.
The facility failed to label, date, and remove expired and spoiled food items from their walk-in refrigerator and freezer, potentially affecting food served to residents. The deficiency was linked to the sudden departure of the Dietary Manager, who was responsible for these tasks. Several undated and improperly stored items were found, and the dietary department was short-staffed, exacerbating the issue.
Three residents experienced inadequate incontinence care, leading to saturated clothing and bedding. A resident with moderate cognitive impairment reported being ignored by night staff, while another resident's family member noted delays in care despite multiple requests. A third resident, cognitively intact, faced extended wait times for assistance due to staffing shortages. The DON confirmed that care should be provided every two hours, but staffing issues hindered this standard.
The facility failed to ensure call lights were within reach for two residents, both requiring assistance due to medical conditions. One resident, with a history of stroke and COPD, often found his call light on the floor or behind the headboard, while another resident, with intervertebral disc degeneration, had her call light placed out of reach on the bed. Staff were unaware or assumed residents could move to access the call lights, leading to residents having to yell for help.
A housekeeping staff member mopped the entire width of a resident hallway, leaving the floor wet and requiring residents, staff, and visitors to walk on the wet surface. This practice was contrary to the facility's training, which instructs staff to mop half of the hallway at a time to prevent falls. Interviews confirmed the unsafe mopping practice, which was observed in one of the facility's hallways.
Two residents in an LTC facility experienced deficiencies in care plan development and implementation. One resident, with chronic pain, did not have a pain management focus in their care plan despite receiving opioids. Another resident, at risk for falls, lacked a fall mat as per their care plan, with staff unaware of the requirement. These issues were confirmed by facility staff.
A resident with chronic respiratory conditions was not receiving oxygen at the prescribed rate of 4 liters per minute. Observations revealed the oxygen concentrator was consistently set at 3.5 liters, despite the resident's reliance on staff due to poor eyesight. The discrepancy was noted by both a nurse and the Unit Manager, who adjusted the flow rate. The DON expected oxygen to be delivered at the ordered rate.
Misappropriation of Resident Funds by Staff Member
Penalty
Summary
The facility failed to protect a resident from misappropriation of personal funds when the Medical Records Manager accepted $280 from Resident #60 for cleaning his personal apartment. The facility’s policy defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident’s belongings or money without the resident’s consent, and the facility’s code of ethics prohibited accepting gifts or gratuities from a patient or family member. Resident #60 was admitted with diagnoses including cerebral infarction and cognitive communication deficit, and a quarterly MDS dated 3/11/26 indicated he was cognitively intact. The Administrator had asked the Activities Director and the former Medical Records Manager to clean the resident’s apartment before discharge, and the Administrator stated the facility would pay them so the resident would have no out-of-pocket expense. Despite this, the resident was later taken to the Medical Records Manager’s home while transportation staff were involved in moving him between locations related to his apartment and rent arrangements. Multiple staff accounts described the resident handing money to the Medical Records Manager at her home on 4/17/26. The Transportation Assistant stated she saw the resident reach into his pocket and give the Medical Records Manager money, and the Transportation Director stated the resident told him the money was because they were supposed to paint his apartment. The Medical Records Manager stated she accepted the money, put it in her work bag, and did not return it at the time. The DON stated the Medical Records Manager later returned $280 to the facility, and the money was counted back to the resident with a signed receipt. The facility’s investigation concluded the Medical Records Manager had accepted money from the resident, and the report identified this as the deficient practice.
Failure to Complete PASRR Screening Before Admission
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed prior to admission for one resident reviewed for PASRR. The resident was admitted from home with a diagnosis of post-traumatic stress disorder and the admission MDS indicated the resident was cognitively intact, was not currently considered by the state Level II PASRR process to have a serious mental illness, and had been identified as having a serious mental illness with a diagnosis of PTSD. The MDS also noted the resident had not exhibited behaviors or rejection of care during the assessment period and had received antipsychotic medications. The North Carolina DHHS PASRR determination letter in the record showed a Level I screen dated 5/11/2023 with a PASRR number valid for the duration of the individual's stay, and stated no additional PASRR screening was required unless there was a significant change in condition suggesting a mental illness diagnosis. In interview, the Social Services Director stated she was responsible for ensuring PASRR was completed prior to admission when required, but did not know the resident needed a new PASRR evaluation because the prior PASRR had no expiration date. The Administrator stated the resident's Level I PASRR screen was provided on admission, that he was unaware a new evaluation was required, and that the Social Services Director was responsible for submitting PASRR requests and evaluations.
Incorrect transcription of protective skin care orders
Penalty
Summary
The facility failed to accurately transcribe and carry out physician orders for protective skin care for Resident #48, who had diagnoses including contractures of both knees and protein calorie malnutrition and was under hospice care for terminal vascular dementia. Her quarterly MDS indicated severely impaired cognition, limited range of motion to both lower extremities, and one unstageable pressure ulcer. Her care plan identified impaired mobility, thin/fragile skin, poor oral intake, and actual skin impairment related to a deep tissue injury to the right hip and blisters to the right inner ankle and left posterior thigh, with interventions to administer treatments as ordered and monitor effectiveness. The physician orders dated 6/26/25 directed Skin Prep to the left great toe twice a day and to the right lateral foot twice a day, both created by the Wound Nurse. The June 2025 TAR instead documented both treatments as daily, and the TAR was initialed as completed once daily. The Wound Nurse confirmed she transcribed the orders incorrectly to the TAR as daily instead of twice a day and stated the Skin Prep was used to toughen the skin to prevent breakdown. The NP stated she expected the orders to be transcribed and carried out correctly, and the DON stated it was her expectation that the protective skin orders be transcribed and carried out correctly.
Oxygen Flow Rate Not Maintained at Ordered Setting
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for a resident admitted with acute and chronic respiratory failure with hypoxia, asthma, alveolar hypoventilation, and acute and chronic respiratory failure with hypercapnia. The resident’s care plan and active order required continuous oxygen at 3 liters per minute via nasal cannula, and the resident was cognitively intact and coded as receiving oxygen therapy. During observations on 5/26/26 and 5/27/26, the oxygen concentrator was seen set at 2.5 liters per minute when viewed at eye level, while the resident was lying in bed wearing the nasal cannula and denied shortness of breath or respiratory distress. On 5/28/26, Nurse #1 observed the concentrator with the surveyor and verified it was set at 2.5 liters per minute, stating it should have been at 3 liters per minute. She reported that she had checked the resident during rounds earlier that morning and found the concentrator set at 3 liters per minute, and believed it may have been bumped afterward. The May 2026 MAR showed oxygen at 3 liters per minute continuously with daily checks and staff initials on all shifts for the dates reviewed. The NP stated staff may not have been reading the oxygen concentrator regulator correctly and explained the bottom of the ball in the flow meter should be at the correct flow rate. The DON and Administrator stated staff should verify the concentrator was set at the ordered flow rate.
Medication Storage and Dating Deficiencies on D Hall Cart
Penalty
Summary
Drugs and biologicals used in the facility were not labeled and stored according to accepted professional principles on 1 of 3 medication carts reviewed, the D Hall cart. Surveyors reviewed manufacturer directions showing that Rhopressa eye drops were to be refrigerated unopened, Brimonidine Tartrate was to be discarded 28 to 30 days after opening, Erythromycin ophthalmic ointment was to be discarded within 28 days of opening, and Latanoprost eye drops were to be discarded four to six weeks after opening. During observation of the D Hall medication cart, surveyors found one unopened bottle of Rhopressa eye drops that was not refrigerated despite the intact manufacturer seal and a label stating to refrigerate until opened. They also found one opened, undated bottle of Brimonidine Tartrate eye drops, one opened, undated tube of Erythromycin ophthalmic ointment, and two opened, undated bottles of Latanoprost eye drops. The MA stated she was unaware the eye drops were not dated when opened and confirmed unopened Rhopressa should have been stored in the refrigerator per the label. The DON stated it was her expectation that nurses and MAs follow manufacturer directions for medication storage and expiration dates, and that the person who opened the medication was responsible for dating it and ensuring it was discarded according to manufacturer guidelines.
Infection Control Lapse with Urinary Catheter Bag
Penalty
Summary
The facility failed to maintain proper infection control practices for a resident with an indwelling urinary catheter. Resident #33, who was cognitively intact, was observed with his urinary catheter drainage bag lying on the floor beside his bed. This occurred because the catheter bag lacked a hook to attach it to the bed frame, which is necessary to prevent the bag from touching the floor and increasing the risk of infection. The Unit Manager acknowledged that the catheter bag was changed during a recent urologist appointment, but the staff did not ensure it was properly secured afterward. Both the Nurse Practitioner and the Director of Nursing confirmed that the catheter bag should not have been on the floor, as it poses an increased risk of infection. The Administrator also agreed that the catheter bag should not have been on the floor, indicating a lapse in the facility's infection control practices.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to ensure a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. In one instance, a bed control cord in a resident's room was found with exposed wires, which had been temporarily covered with yellow electrical tape by the Maintenance Director. The Maintenance Director acknowledged the issue but was unable to specify when the wires were first exposed. Additionally, the PTAC vent in another resident's room was observed to be dirty, with grey dust particles and dried white material, indicating a lack of regular cleaning by the maintenance department. Several resident rooms were found to be in poor condition, with exposed drywall, black scuff marks, and partially painted walls. The Maintenance Director explained that repairs were typically made when rooms became vacant, but he was unable to confirm if specific rooms were scheduled for repair. The housekeeping staff was responsible for cleaning visible dirt, but the maintenance department was tasked with repairing damaged walls. The Administrator emphasized the importance of maintaining a well-kept and homelike environment for residents. Housekeeping practices were also found to be inadequate, as evidenced by the presence of trash and debris under a resident's bed. The Housekeeping Manager stated that personal belongings were not touched to avoid accusations of theft, but acknowledged that trash should have been removed. The Housekeeping District Manager was unaware of this practice and expected rooms to be clean and free of debris. The report highlights a lack of coordination between housekeeping and maintenance, contributing to the deficiencies observed in the facility.
Deficiencies in Nail and Incontinence Care
Penalty
Summary
The facility failed to provide adequate nail and incontinence care for several residents who were dependent on staff for activities of daily living. Observations and interviews revealed that multiple residents had long, jagged, and dirty fingernails, indicating a lack of regular nail care. For instance, one resident with a history of stroke and Alzheimer's disease was observed with jagged fingernails and a yellow-brown substance underneath, despite being scheduled for nail care during showers. Another resident with diabetes and dementia had long fingernails with a black substance underneath, and it was noted that the nursing assistants did not consistently offer or perform nail care. In addition to nail care deficiencies, the facility also failed to provide timely incontinence care. One resident reported wearing a wet brief for an extended period overnight, and another resident's family member noted that staff did not respond promptly to requests for incontinence care, resulting in the resident being left in a saturated state. Interviews with nursing assistants revealed that staffing shortages and lack of communication contributed to these issues, as some staff were unaware of residents' specific care needs or did not have time to address them adequately. The Director of Nursing and Infection Control Nurse acknowledged the deficiencies in nail and incontinence care, noting that nursing assistants were responsible for these tasks but had been lacking in their duties. The facility's documentation and communication processes were also found to be insufficient, as evidenced by incomplete shower sheets and unreported care refusals. These systemic issues led to the observed deficiencies in resident care, impacting the quality of life for those affected.
Inadequate Staffing Leads to Deficient Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, particularly in providing incontinence care and assistance with Activities of Daily Living (ADL) such as nail care. This deficiency affected eight of the eighteen sampled residents, including those who required extensive to total care. Observations and interviews revealed that the facility did not maintain adequate staffing levels, with instances where only one Nursing Assistant (NA) was available to care for over fifty residents. On some occasions, there were no NAs available during certain shifts, leading to delays in providing necessary care. Interviews with staff, including nurses and NAs, highlighted the challenges faced due to inadequate staffing. A nurse reported being overwhelmed and having to work without sufficient NA support, which affected the timely provision of care. NAs also expressed their inability to keep residents dry and perform routine rounds due to being understaffed. The Director of Nursing acknowledged the staffing issues and mentioned efforts to address them, such as requesting agency staff and bonuses, but these were not approved by corporate. The lack of a contingency plan for absent NAs further exacerbated the situation, impacting the quality of care provided to residents.
Care Plan Deficiencies in Resident Assessments
Penalty
Summary
The facility failed to review and revise the care plan for Resident #6 following the most recent Minimum Data Set (MDS) assessment. Resident #6, who was admitted with a history of stroke and chronic obstructive pulmonary disease, had a care plan that included a fall mat to the right side of the bed. This intervention was discontinued in the physician orders on 11/13/24, but the care plan was not updated after the MDS assessment on 12/10/24. An observation on 2/4/25 confirmed the absence of the fall mat, and interviews with the MDS Nurse and Director of Nursing (DON) revealed that the care plan should have been updated to reflect the changes. Resident #31's care plan was not revised to remove the use of quarter side rails, which were discontinued on 2/26/24. Despite the discontinuation, the care plan still included a focus area for the use of side rails. An observation on 2/2/25 confirmed the absence of side rails, and interviews with the Unit Manager and MDS Nurse indicated that the care plan should have been updated to reflect the discontinued use of side rails. The DON confirmed that the care plan should accurately reflect the resident's current needs. Residents #51 and #205 did not have a focus area for Activities of Daily Living (ADL) in their care plans, despite requiring assistance with ADLs. Both residents' baseline care plans indicated a need for assistance, and their MDS assessments confirmed their dependency on staff for various ADLs. Interviews with the MDS Nurse and DON acknowledged the oversight in not including a focus area for ADL care in the residents' care plans, which should have been completed by the time the MDS assessments were finalized.
Delayed Meal Service Due to Staffing Issues and Food Temperature Concerns
Penalty
Summary
The facility failed to serve meals at the posted times on two occasions, affecting the timely delivery of meals to residents. On 2/2/25, lunch was scheduled to be served at 12:00 PM, but residents did not receive their meals until 1:28 PM. This delay was attributed to a staff member calling out without notice, a meal being dropped and needing to be redone, and the presence of state surveyors in the kitchen. Resident #206 was specifically affected, with family members expressing concern over the unpredictability of meal times, which made it difficult to encourage the resident to eat. On 2/3/25, breakfast service was delayed due to the need to reheat food items that were below the required serving temperature and the training of a new cook. The first breakfast cart left the kitchen at 7:50 AM, despite being scheduled for 7:15 AM. The delays were compounded by a staff member calling out and the recent departure of the former Dietary Manager. The new Dietary Manager and a new staff member began working on 2/3/25, which was expected to improve service times.
Improper Food Storage and Labeling in Facility
Penalty
Summary
The facility failed to properly label, date, and remove expired and spoiled food items from their walk-in refrigerator and freezer, which could potentially affect the food served to residents. During an inspection, several items were found undated and improperly stored, including an open box of butter, mozzarella cheese, sour cream, parmesan cheese, and a metal baking pan of gelatin dessert with a frozen white substance on top. Additionally, cucumbers with white fuzzy spots, an undated container of honey, and an undated bottle of lemon juice were observed. In the walk-in freezer, undated and improperly stored items included a box of frozen carrots, a bag of shrimp, a bag of toast, and a box of western-style beef patties that were unwrapped and exposed to air with ice crystals on them. The deficiency was attributed to the sudden departure of the former Dietary Manager, who was responsible for ensuring food was dated and stored correctly. Dietary Aide #1 and Cook #1 confirmed that the Dietary Manager typically handled these tasks, and the dietary department was short-staffed due to a call-out. The District Dietary Manager acknowledged the situation and had communicated with the dietary staff about the importance of dating food. The absence of proper food management practices posed a risk to the quality and safety of food served to residents.
Inadequate Incontinence Care and Staffing Issues
Penalty
Summary
The facility failed to provide adequate incontinence care to maintain the dignity of three residents. Resident #1, who was moderately cognitively impaired, reported that staff did not assist her with incontinence care during the night, resulting in her clothes and bed being saturated. Despite having a note on her door requesting assistance, she stated that the night staff often ignored her call bell. Observations confirmed the presence of a strong urine smell and wet bedding in her room. Nursing assistants provided conflicting accounts of care provided, with one confirming the resident was found soaked without a pull-up. Resident #206, who required assistance with activities of daily living, experienced delays in receiving incontinence care. Her family member reported that despite multiple requests and call bell activations, staff did not respond promptly, leaving the resident and her bed saturated with urine. The resident confirmed these occurrences and expressed discomfort and embarrassment. Attempts to contact the responsible nursing assistant were unsuccessful, highlighting potential staffing issues during the relevant shifts. Resident #9, who was cognitively intact, reported having to wait an extended period for assistance with changing her wet brief during the night. She stated that her call light was turned off without assistance being provided. The nursing assistant on duty acknowledged the difficulty in providing timely care due to being the only staff member on the night shift, exacerbated by staff call-outs. The Director of Nursing confirmed that residents should receive care every two hours, indicating a failure to meet this standard due to staffing shortages.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights for two residents, Resident #6 and Resident #14, were consistently within reach, which is a critical aspect of accommodating their needs and preferences. Resident #6, who was admitted with a history of stroke, chronic pain, and COPD, was observed multiple times with his call light out of reach. Despite being cognitively intact and requiring maximum assistance for activities of daily living, Resident #6 had to rely on yelling for help or waiting for staff to pass by, as his call light was often found on the floor or behind the headboard. Staff interviews revealed that the call light was not consistently clipped to his bed covers, as per his care plan, due to staff being overworked and unaware of its placement. Similarly, Resident #14, who was admitted with intervertebral disc degeneration and a history of falls, also experienced issues with her call light being out of reach. Observations showed that her call light was placed on the floor or in the center of her bed, making it inaccessible from her wheelchair. Despite being cognitively intact and requiring maximal assistance, Resident #14 had to yell for assistance, as she could not safely reach the call light without risking a fall. The nursing assistant responsible for her care admitted to placing the call light in an inaccessible position, assuming the resident could move to reach it if needed. The Director of Nursing acknowledged that staff should ensure call lights are within reach to prevent them from falling or being placed out of reach. The failure to consistently place call lights within reach for these residents highlights a deficiency in accommodating their needs, as both residents were unable to independently access assistance when required, contrary to their care plans.
Unsafe Mopping Practices in Resident Hallway
Penalty
Summary
The facility failed to maintain a safe environment as evidenced by a housekeeping staff member mopping the entire width of the F hallway, which required residents, staff, and visitors to walk on the wet floor. This incident was observed in one out of five resident hallways. During the observation, the Housekeeping Manager was seen mopping the floor at the top of the F Hall and the area in front of the nurse's station, leaving the floor wet completely across the hall. A wet floor sign was placed in the middle of the walkway, but the entire area was wet, posing a risk of falls. Interviews with the Housekeeping Manager and Nurse #1 confirmed the practice of mopping the entire width of the hallway, although the Housekeeping Manager stated that she normally mops half of the hall at a time and waits for it to dry before mopping the other side. The Housekeeping District Manager also confirmed that staff are trained to mop half of the hall at a time to prevent falls. Despite this training, the Housekeeping Manager mopped the entire width of the hallway, creating a hazardous environment.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop an individualized and comprehensive care plan for Resident #21, who was admitted with diagnoses including abnormalities of gait, osteoarthritis, and chronic pain syndrome. Despite the resident reporting varying levels of pain and receiving opioid medications such as oxycodone and morphine sulfate, the care plan updated on January 9, 2025, did not include a focus on pain management. This oversight was confirmed by the MDS nurse and the Director of Nursing, who acknowledged that a focus for pain should have been added to the care plan. Additionally, the facility failed to implement a care plan intervention for safety for Resident #25, who was admitted with diagnoses including Parkinson's disease, muscle weakness, and Alzheimer's disease. The care plan included an intervention to place a fall mat to the left side of the bed, but observations on multiple occasions revealed the absence of the fall mat. Interviews with nurse aides and the Unit Manager indicated a lack of awareness and communication regarding the need for the fall mat, and the Director of Nursing was unable to explain the absence of the fall mat during the specified dates.
Failure to Administer Prescribed Oxygen Rate
Penalty
Summary
The facility failed to administer oxygen at the prescribed rate for a resident with chronic respiratory conditions. Resident #33, who was admitted with chronic respiratory failure, COPD, and congestive heart failure, had a physician's order for continuous oxygen at 4 liters per minute via nasal cannula. However, observations on multiple occasions revealed that the oxygen concentrator was set at 3.5 liters per minute instead of the prescribed 4 liters. This discrepancy was noted during observations on 2/2/25, 2/3/25, 2/4/25, and 2/5/25, despite the Medication Administration Record indicating that the resident was receiving oxygen as ordered. The resident, who was cognitively intact but had poor eyesight, relied on nursing staff to ensure the correct oxygen flow rate. Both Nurse #1 and the Unit Manager observed the incorrect setting and adjusted it to the correct flow rate when standing over the concentrator. The Director of Nursing expressed that it was her expectation for oxygen to be delivered at the ordered rate. The repeated failure to administer the correct oxygen flow rate highlights a deficiency in the facility's respiratory care practices for this resident.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 21 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Albemarle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Trinity Place | 1.4 mi | ★★★★★ | 2 | 0 |
| Stanly Manor | 3.8 mi | ★★★★★ | 7 | 0 |
| Bethany Woods Nursing And Rehabilitation Center | 4.3 mi | ★★★★★ | 9 | 0 |
| Mountain Vista Health Park | 18.4 mi | ★★★★★ | 1 | 0 |
| Autumn Care Of Biscoe | 20.9 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.